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A Stitch in Time

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Open injuries bear the risk of foreign body contamination. Commonly encountered materials include gravel debris, glass fragments, wooden splinters or metal particles. While foreign body incorporation is obvious in some injury patterns, other injuries may not display hints of being contaminated with foreign body materials. Foreign objects that have not been detected and removed bear the risk of leading to severe wound infections and chronic wound healing disorders. Besides these severe health issues, medicolegal consequences should be considered. While an accurate clinical examination is the first step for the detection of foreign body materials, choosing the appropriate radiological imaging is decisive for the detection or non-detection of the foreign material. Especially in cases of impaired wound healing over time, the existence of an undetected foreign object needs to be considered. Here, we would like to give a practical radiological guide for the assessment of foreign objects in head and neck injuries by a special selection of patients with different injury patterns and various foreign body materials with regard to the present literature.
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Objectives The aim of this study was to compare the anesthetic efficacy, the duration of anesthesia, and the postoperative analgesia of lidocaine and bupivacaine and to determine any difference in hemodynamic parameters in patients who required impacted third molar removal. Materials and methods Thirty-eight patients between the ages of 18 and 40, with no systemic disease, were included in the study, with an indication of impacted lower third molar extraction. One of two local anesthetic agents (Marcaine and Jetokain Simplex) was randomly selected for tooth extractions. The parameters evaluated were the onset of anesthetic agent action, the duration of operation, the duration of postoperative analgesia, and postoperative visual analog scale scores. Hemodynamic parameters were observed and evaluated preoperatively and during the operation. All data were evaluated statistically. Results When the time of anesthesia onset was analyzed according to both anesthetic solutions, the difference was in favor of lidocaine (p = 0.01). The duration of action was longer in the bupivacaine group than in the lidocaine group (p = 0.00002). VAS values for the pain obtained during injection were lower in the lidocaine group (p = 0.009).However, according to the results of our study, the postoperative analgesic efficacy of bupivacaine is similar to that of lidocaine (p = 0.087). Conclusion After evaluation of these results, we can recommend the use of lidocaine and bupivacaine safely in dentistry practice. But long-duration effect of bupivacaine and the rapid effect of lidocaine may make lidocaine more preferable. Clinical relevance It is important to determine the clinically effective and safe anesthetic solution.
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Since 2005, a single dose of tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis (Tdap) vaccine has been recommended by the Advisory Committee on Immunization Practices (ACIP) for adolescents and adults (1,2). After receipt of Tdap, booster doses of tetanus and diphtheria toxoids (Td) vaccine are recommended every 10 years or when indicated for wound management. During the October 2019 meeting of ACIP, the organization updated its recommendations to allow use of either Td or Tdap where previously only Td was recommended. These situations include decennial Td booster doses, tetanus prophylaxis when indicated for wound management in persons who had previously received Tdap, and for multiple doses in the catch-up immunization schedule for persons aged ≥7 years with incomplete or unknown vaccination history. Allowing either Tdap or Td to be used in situations where Td only was previously recommended increases provider point-of-care flexibility. This report updates ACIP recommendations and guidance regarding the use of Tdap vaccines (3).
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This report compiles and summarizes all recommendations from CDC's Advisory Committee on Immunization Practices (ACIP) regarding prevention and control of tetanus, diphtheria, and pertussis in the United States. As a comprehensive summary of previously published recommendations, this report does not contain any new recommendations and replaces all previously published reports and policy notes; it is intended for use by clinicians and public health providers as a resource. ACIP recommends routine vaccination for tetanus, diphtheria, and pertussis. Infants and young children are recommended to receive a 5-dose series of diphtheria and tetanus toxoids and acellular pertussis (DTaP) vaccines, with one adolescent booster dose of tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis (Tdap) vaccine. Adults who have never received Tdap also are recommended to receive a booster dose of Tdap. Women are recommended to receive a dose of Tdap during each pregnancy, which should be administered from 27 through 36 weeks' gestation, regardless of previous receipt of Tdap. After receipt of Tdap, adolescents and adults are recommended to receive a booster tetanus and diphtheria toxoids (Td) vaccine every 10 years to assure ongoing protection against tetanus and diphtheria.
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Wound healing after dermal injury is an imperfect process, inevitably leading to scar formation as the skin re-establishes its integrity. The resulting scars have different characteristics to normal skin, ranging from fine-line asymptomatic scars to problematic scarring including hypertrophic and keloid scars. Scars appear as a different colour to the surrounding skin and can be flat, stretched, depressed or raised, manifesting a range of symptoms including inflammation, erythema, dryness and pruritus, which can result in significant psychosocial impact on patients and their quality of life. In this paper, a comprehensive literature review coupled with an analysis of levels of evidence (LOE) for each published treatment type was conducted. Topical treatments identified include imiquimod, mitomycin C and plant extracts such as onion extract, green tea, Aloe vera, vitamin E and D, applied to healing wounds, mature scar tissue or fibrotic scars following revision surgery, or in combination with other more established treatments such as steroid injections and silicone. In total, 39 articles were included, involving 1703 patients. There was limited clinical evidence to support their efficacy; the majority of articles (n = 23) were ranked as category 4 LOE, being of limited quality with individual flaws, including low patient numbers, poor randomisation, blinding, and short follow-up periods. As trials were performed in different settings, they were difficult to compare. In conclusion, there is an unmet clinical need for effective solutions to skin scarring, more robust long-term randomised trials and a consensus on a standardised treatment regime to address all aspects of scarring.
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Many patients suffer from mild, moderate or severe pain during or after root canal therapy. Theoretically, post-operative pain control can be achieved by using long-acting local anesthetics. The aim of this study was to evaluate the efficacy of a long acting anesthesia, bupivacaine, on preventing post-operative pain associated with endodontic treatment, and to compare it with lidocaine. This study was a double blind and randomized clinical trial on 30 patients' anterior maxillary teeth. The patients were divided into two groups of fifteen. One group was administered lidocanine (2% with 1:100000 epinephrine) local anesthesia and the other group was given bupivacaine (0.5% without epinephrine). The pain in patients were compared using the visual analogue scale (VAS) at definite times i.e. before treatment, during treatment and 2,4,6,8,10,12,24,36 and 48 hours after operation. Data were analyzed using One-way ANOVA tests. Bupivacaine significantly decreased postoperative pain compared to lidocaine. Postoperative pain was directly related to preoperative pain. Women reported more pain, though significant difference in postoperative pain report was not found between different ages. In conclusion, a single dose of bupivacaine 0.5% used in infiltration anesthesia could be more effective in reduction or prevention of post-operative endodontic pain compared with lidocaine.
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To investigate the emergency treatment on facial laceration of dog bite wounds and identify whether immediate primary closure is feasible. Six hundred cases with facial laceration attacked by dog were divided into two groups randomly and evenly. After thorough debridement, the facial lacerations of group A were left open, while the lacerations of group B were undertaken immediate primary closure. Antibiotics use was administrated only after wound infected, not prophylactically given. The infection rate, infection time and healing time were analyzed. The infection rate of group A and B was 8.3% and 6.3% respectively (P>0.05); the infection time was 26.3±11.6h and 24.9±13.8h respectively (P>0.05), the healing time was 9.12±1.30d and 6.57±0.49d respectively (P<0.05) in taintless cases, 14.24±2.63d and 10.65±1.69d respectively (P<0.05) in infected cases. Compared with group A, there was no evident tendency in increasing infection rate (8.3% in group A and 6.3% in group B respectively) and infection period (26.3±11.6h in group A and 24.9±13.8h in group B respectively) in group B. Meanwhile, in group B, the wound healing time was shorter than group A statistically in both taintless cases (9.12±1.30d in group A and 6.57±0.49d in group B respectively) and infected cases (14.24±2.63d in group A and 10.65±1.69d in group B respectively). The facial laceration of dog bite wounds should be primary closed immediately after formal and thoroughly debridement. And the primary closure would shorten the healing time of the dog bite wounds without increasing the rate and period of infection. There is no potentiality of increasing infection incidence and infection speed, compared immediate primary closure with the wounds left open. On the contrary, primary closure the wounds can promote its primary healing. Prophylactic antibiotics administration was not recommended. and the important facial organ or tissue injuries should be secondary reconditioned.
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Study objective: Although sterile technique for laceration management continues to be recommended, studies supporting this practice are lacking. Using clean nonsterile gloves rather than individually packaged sterile gloves for uncomplicated wound repair in the emergency department may result in cost and time savings. This study is designed to determine whether the rate of infection after repair of uncomplicated lacerations in immunocompetent patients is comparable using clean nonsterile gloves versus sterile gloves. Methods: A prospective multicenter trial enrolled 816 individuals who were randomized to have their wounds repaired by using sterile or clean nonsterile gloves. The attending physician or resident completed a checklist describing patient, wound, and management characteristics. The patients were provided with a questionnaire to be completed by the physician who removed their sutures at the prescribed time and indicated the presence or absence of infection. When follow-up forms were not returned, a telephone call was made to the patient to determine whether he or she had experienced any wound complications. Results: Follow-up was obtained for 98% of the sterile gloves group and 96.6% of the clean gloves group. There was no statistically significant difference in the incidence of infection between the 2 groups. The infection rate in the sterile gloves group was 6.1% (95% confidence interval [CI] 3.8% to 8.4%) and was 4.4% in the clean gloves group (95% CI 2.4% to 6.4%). The relative risk of infection was 1.37 (95% CI 0.75 to 2.52). Conclusion: This study demonstrated that there is no clinically important difference in infection rates between using clean nonsterile gloves and sterile gloves during the repair of uncomplicated traumatic lacerations.
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To determine if there is a significant difference in the infection rates of wounds irrigated with sterile normal saline (SS) versus tap water (TW), before primary wound closure. Single centre, prospective, randomised, double-blind controlled trial. Wound irrigation solution type was computer randomised and allocation was done on a sequential basis. Stanford University Medical Center Department of Emergency Medicine. Patients older than 1 year of age, who presented to the emergency department with a soft tissue laceration requiring repair, were entered into the study under informed consent. Exclusion criteria included any underlying immunocompromising illness, current use of antibiotics, puncture or bite wounds, underlying tendon or bone involvement, or wounds more than 9 h old. Non-caregivers used a computer generated randomisation code to prepare irrigation basins prior to treatment. Patients had their wounds irrigated either with TW or SS prior to closure, controlling for the volume and irrigation method used. The patient, the treating physician and the physician checking the wound for infection were all blind regarding solution type. Structured follow-up was completed at 48 h and 30 days to determine the presence of infection. The primary outcome measured was the difference in wound infection rates between the two randomised groups. During the 18-month study period, 663 consecutive patients were enrolled. After enrolment, 32 patients were later excluded; 29 patients because they were concurrently on antibiotics; two patients secondary to steroid use and one because of tendon involvement. Of the 631 remaining patients, 318 were randomised into the TW group and 313 into the SS group. Six patients were lost to follow-up (5 SS, 1 TW). A total of 625 patients were included in the statistical analysis. There were no differences in the demographic and clinical characteristics of the two groups. There were 20 infections 6.4% (95% CI 9.1% to 3.7%) in the SS group compared with 11 infections 3.5% (95% CI 5.5% to 1.5%) in the TW group, a difference of 2.9% (95% CI -0.4% to 5.7%). There is no difference in the infection rate of wounds irrigated with either TW or SS solution, with a clinical trend towards fewer wound infections in the TW group, making it a safe and cost-effective alternative to SS for wound irrigation.
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As millions of emergency department (ED) visits each year include wound care, emergency care providers must remain experts in acute wound management. The variety of acute wounds presenting to the ED challenge the physician to select the most appropriate management to facilitate healing. A complete wound history along with anatomic and specific medical considerations for each patient provides the basis of decision making for wound management. It is essential to apply an evidence-based approach and consider each wound individually in order to create the optimal conditions for wound healing. A comprehensive evidence-based approach to acute wound management is an essential skill set for any emergency physician or acute care practitioner. This review provides an overview of current evidence and addresses frequent pitfalls. A systematic review of the literature for acute wound management was performed. A structured MEDLINE search was performed regarding acute wound management including established wound care guidelines. The data obtained provided the framework for evidence-based recommendations and current best practices for wound care. Acute wound management varies based on the wound location and characteristics. No single approach can be applied to all wounds; however, a systematic approach to acute wound care integrated with current best practices provides the framework for exceptional wound management.
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Background: Neutralizing (buffering) lidocaine 1%, epinephrine 1:100,000 solutions (Lido/Epi) with sodium hydrogen carbonate (NaHCO3) (bicarbonate) is widely used to reduce burning sensations during infiltration of Lido/Epi. Optimal mixing ratios have not been systematically investigated. Objectives: To determine whether the Lido/Epi-NaHCO3 mixing ratio 3:1 (IMP1) causes less pain during infiltration than the mixing ratio 9:1 (IMP2) or unbuffered Lido/Epi (IMP3). Methods: Double-blind, randomized, placebo-controlled, crossover trial (n=2x24) with 4 investigational medicinal products (IMP1-4). Results: The 3:1 mixing ratio was significantly less painful than the 9:1 ratio (p = 0.044). Unbuffered Lido/Epi was more painful than the buffered Lido/Epi (p=0.001 vs IMP1; p=0.033 vs IMP2). IMP4 (NaCl 0.9%=placebo) was more painful than any of the anesthetic solutions (p=0.001 vs IMP1; p=0.001 vs IMP2; p=0.016 vs IMP3;). In all cases the anesthesia was effective for at least 3 hours. Limitations: Results of this trial cannot be transferred to other local anesthetics such as prilocaine, bupivacaine, or ropivacaine which precipitate with NaHCO3 admixtures. Conclusions: Lido/Epi-NaHCO3 mixtures effectively reduce burning pain during infiltration. The 3:1 mixing ratio is significantly less painful than the 9:1 ratio. Reported findings are of high practical relevance given the extensive use of local anesthesia today.
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The goals of laceration repair are to achieve hemostasis and optimal cosmetic results without increasing the risk of infection. Many aspects of laceration repair have not changed over the years, but there is evidence to support some updates to standard management. Studies have been unable to define a "golden period" for which a wound can safely be repaired without increasing risk of infection. Depending on the type of wound, it may be reasonable to close even 18 or more hours after injury. The use of nonsterile gloves during laceration repair does not increase the risk of wound infection compared with sterile gloves. Irrigation with potable tap water rather than sterile saline also does not increase the risk of wound infection. Good evidence suggests that local anesthetic with epinephrine in a concentration of up to 1:100,000 is safe for use on digits. Local anesthetic with epinephrine in a concentration of 1:200,000 is safe for use on the nose and ears. Tissue adhesives and wound adhesive strips can be used effectively in low-tension skin areas. Wounds heal faster in a moist environment and therefore occlusive and semiocclusive dressings should be considered when available. Tetanus prophylaxis should be provided if indicated. Timing of suture removal depends on location and is based on expert opinion and experience.
Article
Importance: Whether the use of sterile vs nonsterile gloves in outpatient cutaneous procedures affects the rate of postoperative wound infection is unknown. Objective: To explore rates of surgical site infection (SSI) with the use of sterile vs nonsterile gloves in outpatient cutaneous surgical procedures. Data sources: This systematic review and meta-analysis identified studies from Ovid MEDLINE (1946 to present), Ovid Cochrane Central Register of Controlled Trials (1991 to present), Ovid EMBASE (1988 to present), EBSCO Cumulative Index to Nursing and Allied Health Literature (1980 to present), Scopus (1996 to present), and Web of Science (1975 to present). Study selection: Studies with information on sterile vs nonsterile gloves in outpatient surgical procedures were retrieved. Only randomized clinical trials and comparative studies were included for final analysis. Data extraction: Data of trial design, surgery characteristics, and outcomes from published manuscripts and unpublished data were independently extracted. Main outcomes and measures: Randomized clinical trials were considered high quality if randomization, allocation concealment, blinding, and follow-up completeness were appropriate. Relative risk and 95% CIs were derived for postoperative wound infections. Results: Fourteen articles met eligibility and inclusion criteria for systematic review; they included 12 275 unique patients who had undergone 12 275 unique outpatient procedures with sterile or nonsterile gloves and had follow-up regarding SSI. With the exclusion of 1 single-arm observational study of 1204 patients, 11 071 patients from 13 studies remained in the meta-analysis. Of these, 228 patients were documented as having postoperative SSI (2.1%), including 107 of 5031 patients in the nonsterile glove group (2.1%) and 121 of 6040 patients in the sterile glove group (2.0%). Overall relative risk for SSI with nonsterile glove use was 1.06 (95% CI, 0.81-1.39). Conclusions and relevance: No difference was found in the rate of postoperative SSI between outpatient surgical procedures performed with sterile vs nonsterile gloves.
Article
Animal bites account for 1% of all emergency department visits in the United States and more than $50 million in health care costs per year. Most animal bites are from a dog, usually one known to the victim. Most dog bite victims are children. Bite wounds should be cleaned, copiously irrigated with normal saline using a 20-mL or larger syringe or a 20-gauge catheter attached to the syringe. The wound should be explored for tendon or bone involvement and possible foreign bodies. Wounds may be closed if cosmetically favorable, such as wounds on the face or gaping wounds. Antibiotic prophylaxis should be considered, especially if there is a high risk of infection, such as with cat bites, with puncture wounds, with wounds to the hand, and in persons who are immunosuppressed. Amoxicillin/clavulanate is the first-line prophylactic antibiotic. The need for rabies prophylaxis should be addressed with any animal bite because even domestic animals are often unvaccinated. Postexposure rabies prophylaxis consists of immune globulin at presentation and vaccination on days 0, 3, 7, and 14. Counseling patients and families about animal safety may help decrease animal bites. In most states, physicians are required by law to report animal bites.
Article
When choosing an infiltrative anesthetic agent, the type of procedure, the length of time required for anesthesia, and the pharmacodynamics of each medication are important considerations. Distraction techniques and buffering with sodium bicarbonate can be used to decrease the pain associated with injection. Local cutaneous infiltration is the most commonly used anesthetic technique and involves direct injection into the area requiring anesthesia. Field blocks provide anesthesia by circumferentially blocking innervation to the area. Nerve blocks target the innervation to a specific area and are useful on the face and digits. Using easily identifiable landmarks, blockade of the supraorbital, supratrochlear, infraorbital, and mental nerves can provide site-specific anesthesia. Dorsal and palmar or plantar digital nerve blocks can be performed at a variety of locations on the hands and feet.
Article
Background Bacterial skin and soft tissue infections (SSTIs) in travelers often follow insect bites and can present a broad spectrum of clinical manifestations ranging from impetigo to necrotizing cellulitis. Significant SSTIs can also follow marine injuries and exposures in travelers, and the etiologies are often marine bacteria.Methods To meet the objectives of describing the pathogen-specific presenting clinical manifestations, diagnostic and treatment strategies, and outcomes of superficial and deep invasive infections in travelers caused by commonly encountered and newly emerging marine bacterial pathogens, Internet search engines were queried with the key words as MESH terms.ResultsTravel medicine practitioners should maintain a high index of suspicion regarding potentially catastrophic, invasive bacterial infections, especially Aeromonas hydrophila, Vibrio vulnificus, Chromobacterium violaceum, and Shewanella infections, following marine injuries and exposures.Conclusions Travelers with well-known risk factors for the increasing severity of marine infections, including those with open wounds, suppressed immune systems, liver disease, alcoholism, hemochromatosis, hematological disease, diabetes, chronic renal disease, acquired immunodeficiency syndrome, and cancer, should be cautioned about the risks of marine infections through exposures to marine animals, seawater, the preparation of live or freshly killed seafood, and the accidental ingestion of seawater or consumption of raw or undercooked seafood, especially shellfish. With the exception of minor marine wounds demonstrating localized cellulitis or spreading erysipeloid-type reactions, most other marine infections and all Gram-negative and mycobacterial marine infections will require therapy with antibiotic combinations.
Article
Dog bite wounds represent a major health problem. Despite their importance, their management and especially the role of primary closure remain controversial. In this randomised controlled trial, the outcome between primary suturing and non-closure was compared. 168 consecutive patients with dog bite injuries were included in this study. The wounds were allocated randomly in two treatment approaches: Group 1, consisting of eighty-two patients, had their wound sutured, whilst Group 2, consisting of eighty-six patients, did not have their wounds sutured. All wounds were cleansed using high-pressure irrigation and povidone iodine. All patients received the same type of antibiotic treatment. Our measured outcomes included presence of infection and cosmetic appearance. Cosmetic outcome was evaluated using the Vancouver Scar Scale (VSS). Wound and patient characteristics, such as time of management, wound location and size, and patient age, were recorded and analysed for their potential role in the resulting outcome. The overall infection rate was 8.3%. No difference in the infection rate between primary suturing and non-suturing group was detected in the present study. The cosmetic appearance of the sutured wounds was significantly better (mean score 1.74) compared to the wounds that were left open (mean score 3.05) (p=0.0001). The infection rate was comparable among all age groups. Wounds treated within 8h of injury demonstrated an infection rate of 4.5%, which is lower compared to the 22.2% rate observed in wounds treated later than 8h. The wounds located at the head and neck exhibited better results in both infection rate and cosmetic outcome. Additionally, wounds >3cm negatively affected the cosmetic appearance of the outcome. Primary suturing of wounds caused by dog bites resulted in similar infection rate compared to non-suturing. However, primary suturing exhibited improved cosmetic appearance. Time of management appeared to be critical, as early treatment resulted in lower infection rate and improved cosmetic appearance regardless suturing or not. Furthermore, wounds located at the head and face demonstrated better results.
Article
Objective. —To assess the effect of white petrolatum vs bacitracin ointment on wound infection incidence, allergic contact dermatitis incidence, and healing characteristics.Design. —Randomized,double-blind, prospective trial comparing white petrolatum with bacitracin ointment in postprocedure wound care.Setting. —A general outpatient dermatology clinic and a tertiary referral advanced surgical procedure clinic at Walter Reed Army Medical Center, Washington, DC.Patients. —A total of 922 patients who had dermatologic surgery with a total of 1249 wounds.Main Outcome Measures. —The incidence of infection and allergic contact dermatitis during a follow-up period of 4 weeks. Healing characteristics were secondary outcomes.Results. —Of the 922 patients enrolled, 440 in the white petrolatum group and 444 in the bacitracin group were evaluable for clinical response. The 2 treatment groups had comparable baseline characteristics. Thirteen patients developed postprocedure infection (1.5%), 9 (2.0%) in the white petrolatum group vs 4 (0.9%) in the bacitracin group (95%) confidence interval for difference, -0.4% to 2.7%; P=.37). Eight infections (1.8%) in the white petrolatum group were due to Staphylococcus aureusvs none in the bacitracin group (P=.004). No patient in the group using white petrolatum developed allergic contact dermatitis vs 4 patients (0.9%) in the group using bacitracin (P=.12). Additionally, there were no clinically significant differences in healing between the treatment groups on day 1 (P=.98), day 7 (P=.86), or day 28 (P=.28) after the procedure.Conclusions. —White petrolatum is a safe, effective wound care ointment for ambulatory surgery. In comparison with bacitracin, white petrolatum possesses an equally low infection rate and minimal risk for induction of allergy.
Article
Roentgenograms of 66 different kinds of glass fragments embedded in chicken legs were taken to evaluate the roentgenographic detectability of glass in an animal tissue similar in size and structure to the human hand or foot. All 66 specimens were easily seen. The presence of lead or other heavy elements was not required for visualization. Fragments as small as 0.5 mm were easily detected if there was no overlying bone. Standard plain x-ray films of the injured hand or foot are useful in determining whether glass fragments are present in the wound.(JAMA 1982;248:1872-1874)
Article
Introduction: Animal bite wounds are a significant problem, which have caused several preventable child deaths in clinical practice in the past. The majority of bite wounds is caused by dogs and cats, and also humans have to be considered to lead to those extreme complicated diagnosis in the paediatric patient population. Early estimation of infection risk, adequate antibiotic therapy and, if indicated, surgical treatment, are cornerstones of successful cures of bite wounds. However, antibiotic prophylaxis and wound management are discussed controversially in the current literature. In our study, we retrospectively investigated the bite source, infection risk and treatment options of paediatric bite wounds. Methods: A total of 1592 paediatric trauma patients were analysed over a period of 19 years in this retrospective study at a level I trauma centre, Department of Trauma Surgery, Medical University of Vienna, Austria. Data for this study were obtained from our electronic patient records and follow-up visits. In our database, all paediatric patients triaged to our major urban trauma centre have been entered retrospectively. Results: During the 19-year study period, 1592 paediatric trauma patients met the inclusion criteria. The mean age was 7.7 years (range 0-18.9), 878 (55.2%) were males and 714 (44.8%) were females. In our study population, a total of 698 dog bites (43.8%), 694 human bites (43.6%), 138 other bites (8.7%) and 62 cat bites (3.9%) have been observed. A total of 171 wounds (10.7%) have been infected. Surgical intervention was done in 27 wounds (1.7%). Conclusion: Gender-related incidence in bite wounds for dog and cat could be detected. Second, our findings for originator of bite wounds reflect the findings in the published literature. Total infection rate reached 10.7%, primary antibiotic therapy was administered in 221 cases (13.9%) and secondary antibiotic therapy in 20 (1.3%) cases. Observed infection rate of punctured wounds and wounds greater than 3 cm was 3 times higher than for all other wounds. Our findings need to be proven in further prospective clinical trials.
Article
The evidence base underpinning most traditional scar reduction approaches is limited, but some of the novel strategies are promising and accumulating. We review a number of commonly adopted strategies for scar reduction. The outlined novel agents are paradigmatic of the value of translational medical research and are likely to change the scenery in the much neglected but recently revived field of scar reduction therapeutics.
Article
To determine the effects of warming and buffering of 0.5% bupivacaine on the pain associated with intradermal injection and the time of onset of anesthesia, 40 adult volunteers were entered into a randomized, double-blind study conducted at a community teaching hospital. The three-part study compared room temperature (20 degrees) bupivacaine buffered to a pH of 7.1 with the following solutions: buffered bupivacaine warmed to 37 degrees C, unbuffered bupivacaine at room temperature, and unbuffered bupivacaine warmed to 37 degrees C. The same crossover protocol was followed for each part of the study. Subjects received 0.5-mL intradermal injections through 27-gauge needles over 30 seconds, one study solution in each forearm. Immediately after each injection, pain was assessed using a 100-mm visual analog pain scale. The time of onset of anesthesia (loss of intradermal sensation to pinprick) was measured by stopwatch. The mean perceived pain score for the warm buffered bupivacaine (51 mm) was significantly lower than for the room temperature buffered solution (63 mm, P = .003). Similarly, there was a statistical difference between the room temperature buffered and unbuffered solutions (65 v 78 mm, P < .001). The differences in mean pain scores for the room temperature buffered bupivacaine, compared with the other three solutions, suggest that warming and buffering have an additive effect. In this model, the latency of action of bupivacaine was not affected by alkalinization. However, warming bupivacaine to 37 degrees C reduced the time of onset to intradermal anesthesia by 12.1 seconds (95% confidence interval, 0.6 to 23.6). These results suggest that warming is more effective than buffering to reduce the pain of infiltration of bupivacaine and the time of onset of intradermal anesthesia.
Article
Skin laceration repair is an important skill in family medicine. Sutures, tissue adhesives, staples, and skin-closure tapes are options in the outpatient setting. Physicians should be familiar with various suturing techniques, including simple, running, and half-buried mattress (corner) sutures. Although suturing is the preferred method for laceration repair, tissue adhesives are similar in patient satisfaction, infection rates, and scarring risk in low skin-tension areas and may be more cost-effective. The tissue adhesive hair apposition technique also is effective in repairing scalp lacerations. The sting of local anesthesia injections can be lessened by using smaller gauge needles, administering the injection slowly, and warming or buffering the solution. Studies have shown that tap water is safe to use for irrigation, that white petrolatum ointment is as effective as antibiotic ointment in postprocedure care, and that wetting the wound as early as 12 hours after repair does not increase the risk of infection. Patient education and appropriate procedural coding are important after the repair.
Article
The choices of wound management are limited to either surgical repair or healing by secondary intention. Use of secondary intention healing is the oldest method, antedating the practice of medicine, but its use has declined since surgical techniques have been developed, refined, and popularized. Now secondary intention healing is used mostly for small superficial surgical wounds, lacerations, abrasions, chronic ulcers, and for wounds created by destructive methods such as electrodessication, cryosurgery, or chemical cautery. These applications are known well to dermatologists, but are less often used by other surgeons except when wounds have persisted after surgical repair, become infected, or result from necrosis of flaps or grafts.Even among dermatologic surgeons the interest in plastic and reconstructive techniques has overshadowed the importance and advantages of secondary intention healing. In the past several decades, only a small number of reports has appeared discussing the use of secondary intention healing for wounds that are traditionally managed by surgical repair.1–10 These reports “rediscovered” the often amazing cosmetic results that follow secondary intention healing. There remains a reluctance to use this method to its fullest advantage. This is partly due to fear that open wounds heal inordinately slowly with complications of pain, bleeding, infection, and horrible scarring, and partly due to the conceit that our surgical skills are superior to Mother Nature's own way. There is an immediate gratification that occurs after the successful repair of a large wound. This feeling is difficult to sacrifice, especially if the results of secondary intention healing cannot be predicted. This chapter will review the advantages of secondary intention healing and provide a set of guidelines that will enable one to predict the cosmetic results of wounds allowed to heal by this method.
Article
Dermabond is a cyanoacrylate tissue adhesive that forms a strong bond across apposed wound edges, allowing normal healing to occur below. It is marketed to replace sutures that are 5-0 or smaller in diameter for incisional or laceration repair. This adhesive has been shown to save time during wound repair, to provide a flexible water-resistant protective coating and to eliminate the need for suture removal. The long-term cosmetic outcome with Dermabond is comparable to that of traditional methods of repair. Best suited for small, superficial lacerations, it may also be used with confidence on larger wounds where subcutaneous sutures are needed. This adhesive is relatively easy to use following appropriate wound preparation. Patients, especially children, readily accept the idea of being "glued" over traditional methods of repair.
Article
The prohibition against the use of local anesthetics with epinephrine for digital blocks or infiltration is an established surgical tradition. The present article provides a comprehensive review of all reported digital necrotic and ischemic complications with epinephrine in the digits in an effort to understand whether the current prohibition is based on documented reports. A comprehensive review of articles showing the successful use of local anesthetic with epinephrine in the digits is presented.A review of Index Medicus from 1880 to 1966 and a computer review of the National Library of Medicine database from 1966 to 2000 were performed using multiple keywords. Selected major textbooks from 1900 to 2000 were also reviewed.A total of 48 cases of digital gangrene after anesthetic blocks (mostly using cocaine or procaine) have been reported in the world literature. Only 21 cases involved the use of epinephrine; 17 involved an unknown concentration based on manual dilution. Multiple other concurrent conditions (hot soaks, tight tourniquets, and infection) existed in these case reports, making it difficult to determine the exact cause of the tissue insult. There have been no case reports of digital gangrene using commercial lidocaine with epinephrine (introduced in 1948). Multiple studies involving thousands of patients support the premise that the use of lidocaine with epinephrine is safe in the digits. An extensive literature review failed to provide consistent evidence that our current preparations of local anesthesia with epinephrine cause digital necrosis, although not all complications are necessarily reported. However, as with all techniques, caution is necessary to balance the risks of this technique with the dangers of mechanical tourniquets and upper extremity block anesthesia.
Article
Most lacerations and surgical incisions are closed with sutures or staples. Octylcyanoacrylate tissue adhesive (OCA) was recently approved for use in the United States. We compared the cosmetic appearance of lacerations and incisions repaired with OCA versus standard wound closure methods (SWC). A multicenter randomized clinical trial including patients with simple lacerations or surgical incisions was conducted at 10 clinical sites. Patients were randomly assigned to treatment with OCA or SWC. Follow-up was performed at 1 week and at 3 months to determine infection rates and cosmetic outcome. Eight hundred fourteen patients with 924 wounds (383 traumatic lacerations, 235 excisions of skin lesions or scar revisions, 208 minimally invasive surgeries, and 98 general surgical procedures) were enrolled. Groups were similar in baseline characteristics. Wound closure with OCA was faster than with SWC (2.9 vs 5.2 minutes, P <.001). At 1 week infection rates were similar (OCA, 2.1% vs SWC, 0.7%; P =.09) and fewer OCA wounds were erythematous (18% vs 36%, P <.001). There were no differences in wound dehiscence rates (OCA, 1.6% vs SWC, 0.9%; P =.35). At 3 months there was no difference in the percent of wounds with optimal appearance (OCA, 82% vs SWC, 83%; P =.67). Repair of traumatic lacerations and surgical incisions with OCA is faster than with SWC, and cosmetic outcome is similar at 3 months.
Article
Study objective: We evaluate a new technique of treating scalp lacerations, the hair apposition technique (HAT). After standard cleaning procedures, hair on both sides of a laceration is apposed with a single twist. This is then held with tissue adhesives. HAT was compared with standard suturing in a multicenter, randomized, prospective trial. Methods: All linear lacerations of the scalp less than 10 cm long were included. Severely contaminated wounds, actively bleeding wounds, patients with hair strand length less than 3 cm, and hemodynamically unstable patients were excluded. Patients were randomized to receive either HAT or standard suturing, and the time to complete the wound repair was measured. All wounds were evaluated 7 days later in a nonblinded manner for satisfactory wound healing, scarring, and complications. Results: There were 96 and 93 patients in the study and control groups, respectively. Wound healing trended toward being judged more satisfactory in the HAT group than standard suturing (100% versus 95.7%; P =.057; effect size 4.3%; 95% confidence interval 0.1% to 8.5%). Patients who underwent HAT had less scarring (6.3% versus 20.4%; P =.005), fewer overall complications (7.3% versus 21.5%; P =.005), significantly lower pain scores (median 2 versus 4; P <.001), and shorter procedure times (median 5 versus 15 minutes; P <.001). There was a trend toward less wound breakdown in the HAT group (0% versus 4.3%; P =.057). When patients were asked whether they were willing to have HAT performed in the future, 84% responded yes, 1% responded no, and 15% were unsure. Conclusion: HAT is equally acceptable and perhaps superior to standard suturing for closing suitable scalp lacerations. Advantages include fewer complications, a shorter procedure time, less pain, no need for shaving or removal of stitches, similar or superior wound healing, and high patient acceptance. HAT has become our technique of choice for suitable scalp lacerations.[Ong Eng Hock M, Ooi SBS, Saw SM, Lim SH. A randomized controlled trial comparing the hair apposition technique with tissue glue to standard suturing in scalp lacerations (HAT study).
Article
Irrigation, a critical component of wound management, is commonly performed with sterile normal saline solution. The purpose of this study was to compare the infection rates of wounds irrigated with normal saline solution versus those of wounds irrigated with running tap water. A prospective trial was conducted in an urban pediatric emergency department. Tap water pressure and flow rates were measured, and cultures were obtained before the study and at 5 months after study initiation. Patients 1 to 17 years of age presenting to the pediatric ED with a simple laceration were eligible. Exclusion criteria included immunocompromise, complicated lacerations, or current use of or need for antibiotics. Patients were allocated to the running tap water group or the standard normal saline solution irrigation group. Wounds were closed in standard fashion. Patients returned to the pediatric ED in 48 to 72 hours for evaluation. Two hundred seventy-one patients were enrolled in the normal saline solution group and 259 in the tap water group. Tap water and normal saline solution pressures and flow rates differed. The groups did not differ in terms of patient demographic characteristics or wound characteristics. However, more wounds were located on the hand in the tap water group (21.3%; 95% confidence interval [CI] 16.3% to 27.1%) compared with those in the normal saline solution group (9.2%; 95% CI 5.9% to 13.4%). The wound infection rates were similar in the 2 groups (normal saline solution group: 2.8% [95% CI 1.1% to 5.7%] versus running tap water group: 2.9% [95% CI 1.2% to 5.9%]). There were no clinically important differences in infection rates between wounds irrigated with tap water or normal saline solution. Tap water might be an effective alternative to normal saline solution for wound irrigation in children.
Article
Foreign bodies are uncommon, but they are important and interesting. Foreign bodies may be ingested, inserted into a body cavity, or deposited into the body by a traumatic or iatrogenic injury. Most ingested foreign bodies pass through the gastrointestinal tract without a problem. Most foreign bodies inserted into a body cavity cause only minor mucosal injury. However, ingested or inserted foreign bodies may cause bowel obstruction or perforation; lead to severe hemorrhage, abscess formation, or septicemia; or undergo distant embolization. Motor vehicle accidents and bullet wounds are common causes of traumatic foreign bodies. Metallic objects, except aluminum, are opaque, and most animal bones and all glass foreign bodies are opaque on radiographs. Most plastic and wooden foreign bodies (cactus thorns, splinters) and most fish bones are not opaque on radiographs. All patients should be thoroughly screened for foreign bodies before undergoing a magnetic resonance imaging study.
Article
Patient comfort is an important part of laceration repair. The study was a randomized single-blind cross-over trial in which each participant received 250 ml warmed and 250 ml room temperature saline irrigation in simple linear wounds after a local anesthetic was instilled. The solutions and the order of irrigation (warmed first versus second) were separately randomized with a washout period between. Investigators obtaining scores were blinded. Participants determined preferred solution, whether the solution was soothing, and which caused the most discomfort. Participants rated the pain of irrigation using separate Visual Analog Scale scores. Thirty-eight patients were enrolled in the study. Significantly more preferred warmed to room temperature solutions (difference, 34%; 95% confidence interval, 5.7-63). A Wilcoxon signed-rank test for paired data showed no order effect (P = 0.49) or difference in pain measured according to the Visual Analog Scale (P = 0.082). Warmed saline was more comfortable and soothing than room temperature saline as a wound irrigant among patients with linear lacerations.
Article
Wounds sustained in oceans, lakes, and streams are exposed to a milieu of bacteria rarely encountered in typical land-based injuries. These include Vibrio species, Aeromonas hydrophila, Pseudomonas and Plesiomonas species, Erysipelothrix rhusiopathiae, Mycobacterium marinum, and other microbes. Failure to recognize and treat these less common pathogens in a timely manner may result in significant morbidity or death. Initial antibiotic therapy should address common gram-positive and gram-negative aquatic bacteria, depending on the environment. Trauma occurring in brackish or salt water should be treated with doxycycline and ceftazidime, or a fluoroquinolone (eg, ciprofloxacin or levofloxacin). Freshwater wounds should be managed with ciprofloxacin, levofloxacin, or a third- or fourth-generation cephalosporin (eg, ceftazidime). Injuries sustained in a marine or freshwater environment may result from bites or venomous stings of aquatic organisms as well as from accidental trauma. Musculoskeletal trauma caused by venomous underwater species (eg, stingrays, stinging fish, sea urchins, and coral) requires immediate neutralization of the heat-labile toxin with immersion in nonscalding water for 30 to 90 minutes. Appropriate management of aquatic wounds requires recognition of the mechanism of injury, neutralization of venom, antibiotic administration, radiographic assessment, surgical débridement with irrigation, wound cultures, and structural repair or amputation as indicated by the severity of the injury.
Article
Medical texts continue to perpetuate the belief that epinephrine should not be injected in fingers. Little attention has been paid to analyze the evidence that created this belief to see whether it is valid. The significance is that elective epinephrine finger injection has been shown to remove the need for a tourniquet, and therefore delete sedation and general anesthesia for much of hand surgery. All of the evidence for the antiadrenaline dogma comes from 21 mostly pre-1950 case reports of finger ischemia associated with procaine and cocaine injection with epinephrine. The authors performed an in-depth analysis of those 21 cases to determine their validity as evidence. They also examined in detail all of the other evidence in the literature surrounding issues of safety with procaine, lidocaine, and epinephrine injection in the finger. The adrenaline digital infarction cases that created the dogma are invalid evidence because they were also injected with either procaine or cocaine, which were both known to cause digital infarction on their own at that time, and none of the 21 adrenaline infarction cases had an attempt at phentolamine rescue. The evidence that created the dogma that adrenaline should not be injected into the fingers is clearly not valid. However, there is considerable valid evidence in the literature that supports the tenet that properly used adrenaline in the fingers is safe, and that it removes the need for a tourniquet and therefore removes the need for sedation and general anesthesia for many hand operations.
Article
Hypertrophic scars, resulting from alterations in the normal processes of cutaneous wound healing, are characterized by proliferation of dermal tissue with excessive deposition of fibroblast-derived extracellular matrix proteins, especially collagen, over long periods, and by persistent inflammation and fibrosis. Hypertrophic scars are among the most common and frustrating problems after injury. As current aesthetic surgical techniques become more standardized and results more predictable, a fine scar may be the demarcating line between acceptable and unacceptable aesthetic results. However, hypertrophic scars remain notoriously difficult to eradicate because of the high recurrence rates and the incidence of side effects associated with available treatment methods. This review explores the various treatment methods for hypertrophic scarring described in the literature including evidence-based therapies, standard practices, and emerging methods, attempting to distinguish those with clearly proven efficiency from anecdotal reports about therapies of doubtful benefits while trying to differentiate between prophylactic measures and actual treatment methods. Unfortunately, the distinction between hypertrophic scar treatments and keloid treatments is not obvious in most reports, making it difficult to assess the efficacy of hypertrophic scar treatment.
A multicenter comparison of tap water versus sterile saline for wound irrigation
  • Moscati
Do topical antibiotics help prevent infection in minor traumatic uncomplicated soft tissue wounds?
  • Waterbook
Laceration repair with sutures, staples, and wound closure tapes
  • McNamara